United Nations Directories for Electronic Data Interchange for
Administration, Commerce and Transport

UN/EDIFACT

Message Type : IHCEBI
Version : D
Release : 12B
Contr. Agency: UN
Revision : 1
Date : 2012-11-02
SOURCE: TBG10 Healthcare
CONTENTS
Interactive health insurance eligibility and benefits inquiry and response
0. INTRODUCTION
1. SCOPE
1.1 Functional definition
1.2 Field of application
1.3 Principles
2. REFERENCES
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
3.2 Message terms and definitions
4. MESSAGE DEFINITION
4.1 Segment clarification
4.2 Segment index (alphabetical sequence by tag)
4.3 Message structure
4.3.1 Segment table
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For general information on UN standard message types see UN Trade Data
Interchange Directory, UNTDID, Part 4, Section 2.3, UN/ECE UNSM
General Introduction
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0. INTRODUCTION
This specification provides the definition of the Interactive health
insurance eligibility and benefits inquiry and response (IHCEBI) to
be used in Electronic Data Interchange (EDI) between trading
partners involved in administration, commerce and transport.
1. SCOPE
The Interactive health insurance eligibility benefit inquiry and
response message may be used for both national and international
applications. It is based on universal practices related to
administration, commerce and transport, and is not dependent on the
type of business or industry.
In particular, IHCEBI can be applied to all types of health care
service providers, funding institutions and health care delivery
systems.
1.1 Functional definition
The IHCEBI message is sent from institutional or individual health
care providers or those providing related administrative services to
a funding institution to obtain health insurance information from a
patientís health plan prior to or at the time of admission or
treatment.
This inquiry message will allow a health care provider to give their
patient an estimate of cost for certain treatments, or assess their
own financial risk associated with certain treatments, and provide
the patient with informed financial choices regarding their health
care options.
Each inquiry can provide information to the health plan about a
service being considered, (e.g., actual or expected service dates,
actual or expected duration of hospital stay, and planned services).
An inquiry can also contain information about the treating and
referring practitioner, if they are not the health care party making
the inquiry.
The response message will provide information regarding what
benefits are available to the patient based on their health plan
contract and the information provided with the inquiry. This can
include financial information, such as, co-pay amounts, deductible
amounts, limitations, and exclusions.
Each response can also provide information regarding administrative
issues concerning a covered benefit, such as, indicate who is the
primary provider for a service, contact information for the health
plan and patient, and policy rules, such as, certain screening exams
can only be done once every two years.
1.2 Field of application
The Interactive health insurance eligibility and benefits inquiry
and response may be used for both national and international
applications. It is based on universal practice related to
administration, commerce and transport, and is not dependent on the
type of business or industry.
1.3 Principles
The IHCEBI message can carry either an initial inquiry,
modifications to an inquiry made in a previous eligibility request
and response message from the funding institution.
An inquiry can only concern one patient or health plan subscriber,
but may concern one or more services or procedures regarding an
individual patient or subscriber. A response is limited to
providing an answer to the questions asked about a patient or health
plan subscriber, but may report benefits for multiple family
members.
2. REFERENCES
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction,
Section 1.
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction,
Section 2.
3.2 Message terms and definitions
Capitated provider - is a term that describes a provider who is
under contract with a health plan and the provider agrees to receive
a monthly capitation payment amount per patient each month in lieu
of fee for service payment or charges. Under this arrangement a
provider cannot charge for services rendered that are described in
their contract, for example, routine well visits or sick visits.
4. MESSAGE DEFINITION
4.1 Segment clarification
This section should be read in conjunction with the segment table
which indicates mandatory, conditional and repeating requirements.
00010UIH, Interactive message header
A service segment starting and uniquely identifying a message. The
message type code for the Interactive health insurance eligibility
and benefits inquiry and response is IHCEBI.
Note: Interactive health insurance eligibility and benefits inquiry
and responses conforming to this document must contain the
following data in segment UIH, composite S306:
Data element 0065 IHCEBI
0052 D
0054 12B
0051 UN
00020MSD, Message action details
Use to specify the message and processing requirements, for
example, the type of health care insurance verification to be done
and to provide a tracking mechanism for the submitter of
the message. The reference number in this segment will provide an
application level tracking number, which is different from what is
generated in the message envelope.
00030 Segment group 1: PRT-NAA-CON-FRM
Associated Parties Group:
A group of segments that will be repeated once for each party
involved with this eligibility message, used to identify and
provide information about each party by code and name. Parties may
include and a loop would be present for:
1) Submitter - when serving as an agent for the provider,
2) Requester - either a provider, payer, or employer making a
request,
3) Responder - either a payer or a third party administrator when
serving as an agent for the payer,
4) Subscriber - will always be present, and
5) Patient - present only when patient is not the subscriber.
In the response message the responder may optionally add one or
more entries to this loop to identify a patient's primary care
physician (PCP) or specialist, if the provider making the inquiry
is not the patient's PCP or specialist. Other parties may also be
added to identify other capitated providers associated with the
patient care and health plan.
00040PRT, Party information
To provide specific entity identifiers or demographic
information regarding the identity of the participating parties.
For individuals identifiers will include date of birth, or a
health plan insurance card date of issue as shown on the card
may be specified in this segment, when the segment is
identifying a health plan subscriber.
00050NAA, Name and address
Use to specify a party identity, and when necessary, the name
and address of an entity and their related function in either a
structured or unstructured format. For use in health care, it
is recommended to use only the name and identifier, but when
name and address are required use only the structured method of
submittal. This segment is providing the name and address of
the party identified in the Associated Parties Group.
00060CON, Contact information
Use to specify contact communication numbers, names, and
electronic message routing information. Use to provide
information about contacts within an organization or associated
with the party identified in the Associated Parties Loop who can
be called upon for further or clarifying information. The
reference number may be used to provide a unique number for the
contact entity to use when referring to this message.
00070FRM, Follow-up action
Used only with the response message, this will identify specific
corrective actions or follow-up that should occur before another
inquiry is made about this entity. Errors reported here related
to the parties identified in the Associated Parties Group. For
example, provider is not authorised to inquire against this
payer's files.
00080 Segment group 2: DTI-ICI-FRM-SG3
Global Benefit Service Details Group:
This group of segments will occur only once for an eligibility
request or response. It provides coverage or service information
that is common for each health insurance benefit and service
coverage reported.
00090DTI, Date and time information
Use to specify dates that will common to each benefit or covered
service.
On the request message, this segment will be used to specify the
service or planned service dates for the benefits in question.
On the response message, this segment will specify the effective
dates of benefit coverage for all listed benefits. The
information in this segment can be overridden for a specific
benefit, when effective or termination dates are different from
the overall plan. This is done in the Health Insurance Benefit
Details Group for each reported benefit where it applies.
00100ICI, Insurance cover information
Use to specify a type of insurance, this will apply to all
information that follows.
00110FRM, Follow-up action
To identify specific corrective actions or follow-up that should
occur before another inquiry is made about the patient in the
request message. This segment is only sent with the response
message when there are errors to report related to the benefit
information request message within the Global Benefit and
Service Coverage Group. For example, an invalid service date or
insurance type was specified.
00120 Segment group 3: BCD-HDS-DTI-PRT-FRM
Health Insurance Benefit Details Group:
This segment group provides health insurance coverage and
benefit information about a particular personís health insurance
plan. This segment group can be repeated to describe each
benefit or covered service in question. Each benefit or covered
service will require a separate repetition.
When this message is sent as a request for health insurance
available benefits and coverage, it will specify the type of
health benefit information that is required.
When this message is sent in response to a request, this segment
group will provide the requested health insurance coverage and
benefit information as requested by the inquiry.
00130BCD, Benefit and coverage detail
Use to specify specific benefits and associated coverage.
When used on the request message, it will specify a specific
benefit or covered service in question.
When used on the response, it will provide information about
the requested health insurance benefits and coverage
available, plus any additional administrative information
that may have a business or patient care impact to the party
making the inquiry.
00140HDS, Health diagnosis service and delivery
Use to specify diagnosis information and procedure or therapy
services and details about how and when these services can be
delivered, based on the diagnosis or procedure or contract
terms or all of these.
When this information is sent on the request, it is
describing the diagnosis of the patient and asking about
benefit coverage for a specific procedure or therapy.
When the information is sent on the response, it is providing
information from the health insurance plan about what benefit
coverage is available, for certain procedures based on the
diagnosis and what service delivery requirements exist, which
can vary based on diagnosis, procedure, and health plan
contract.
00150DTI, Date and time information
Use to specify eligibility dates related to the benefit or
service described in the current iteration of the Health
Insurance Benefit Details Group.
When used at this level on the request message, it is to
specify service dates from the provider that are outside of
the service dates specified in the Global Benefit Service
Details Group.
When used at this level on the response message it identifies
eligibility start or termination dates assigned by the
responder that override the overall eligibility dates
identified in the earlier Global Benefit Service Details
Group.
00160PRT, Party information
Use to reference a specific payer or provider for the benefit
or service identified in the current Health Insurance Benefit
Details Group. The payer or provider should be in the list
of parties identified within the Associated Parties Group,
where full details of the entity should be provided,
including name, address, and contact information. The payer
is most likely used for third party liability for
coordination of benefits. Identified providers would be
those restricted to providing services for the identified
benefit, for example, a capitated provider.
00170FRM, Follow-up action
Use to identify specific corrective actions or follow-up that
should occur before another inquiry is made about this
subject entity, that is, the patient or health plan
subscriber. Errors reported at this level of the message are
benefit specific, reporting processing errors from the
responding application associated with the benefit inquiry
request.
00180UIT, Interactive message trailer
A service segment ending a message, giving the total number of
segments in the message (including the UIH & UIT) and the control
reference number of the message.
4.2 Segment index (alphabetical sequence by tag)
BCD Benefit and coverage detail
CON Contact information
DTI Date and time information
FRM Follow-up action
HDS Health diagnosis service and delivery
ICI Insurance cover information
MSD Message action details
NAA Name and address
PRT Party information
UIH Interactive message header
UIT Interactive message trailer